Indicators of acute otitis media severity - Prof. Tal Marom

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ACUTE OTITIS MEDIA: INDICATIORS OF DISEASE SEVERITY Tal Marom, MD 1 Sharon Ovnat Tamir, MD 2 1 Department of Otolaryngology-Head and Neck Surgery, Assaf Harofeh Medical Center; 2 Department of Otolaryngology-Head and Neck Surgery, Edith Wolfson Medical Center; Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel

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  • ACUTE OTITIS MEDIA: INDICATIORS OF DISEASE SEVERITY

    Tal Marom, MD1Sharon Ovnat Tamir, MD2

    1Department of Otolaryngology-Head and Neck Surgery,Assaf Harofeh Medical Center;

    2Department of Otolaryngology-Head and Neck Surgery,Edith Wolfson Medical Center;

    Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel

  • Tel Aviv University

  • Outline AOM risk factors Severity Scores

    Assessment of signs Assessment of symptoms Assessment of signs and symptoms Assessment of physical examination findings Assessment of laboratory findings

    Conclusion

  • Classic Risk Factors for AOM

    Factors that can not be modified : Boys Age < 2 years Older siblings Lack of breastfeeding Season (fall, winter)

    Factors that can be modified: Pacifier use Passive smoke exposure Day care attendance Low socioeconomic status

  • Risk Factors for Treatment Failure or Recurrence

    Antibiotic therapy within the last 1 month Any AOM diagnosis within the last 1 month > 3 AOM episodes / last 6 months Age < 2 years Age at 1st AOM episode < 6 months Day care attendance Bilateral AOM (?)

  • Reports Linking Severity of AOM to Streptococcus pneumoniae

    Coffey et al. reported an association between Streptococcus pneumoniae with bullous myringitis.

    Howie et al. reported more pain and fever in children with pneumococcal AOM.

    Rodriguez et al. described higher fever and more intensely yellow/red and bulging tympanic membranes (TMs) in AOM associated with S. pneumoniae.

  • Acute Otitis Media Severity of Symptoms (AOM SOS) Score

    This Score indicates the severity of the following 7 directly observable behaviors: Ear tugging Crying Fussiness Disturbed sleep Decreased play Eating less Fever

    Children with pneumococcal AOM had higher scoresShaikh et al. Acute otitis media severity of symptom score in a tympanocentesis study. PIDJ 2011

  • AOM Facies Score

    Friedman et al. Development of a Practical Tool for Assessing the Severity of Acute Otitis Media. Pediatric Infectious Disease Journal. 25(2):101-107, February 2006.

    No correlation stated between AOM FS and pneumococcal disease

  • Ear Treatment Group 5 Items (ETG-5)

    Parents use this scale to grade the following: fever, 0 = 39C

    ear ache (tugging), 0 = none, 4 = occasional or 7 = frequent

    irritability, 0 = none, 4 = occasional, or 7 = frequent

    0 = feeds well, 4 = mild decrease in appetite or 7 = very poor appetite

    0 = normal sleep, 4 = somewhat restless sleep or 7 = very poor sleep

    Symptom score did not differ between bacterial and non-bacterial pathogens

    McCormick et al. Otitis media: can clinical findings predict bacterial or viral etiology? Pediatr Infect Dis J. 2000;

  • Otologic System 8 (OS-8) 0 = normal, or effusion without erythema 1 = erythema only, no effusion 2 = erythema, air fluid level, clear fluid 3 = erythema, complete effusion, no opacification 4 = erythema, opacification with air-fluid level or air bubble(s), no bulging 5 = erythema, complete effusion, opacification and no bulging 6 = erythema, bulging rounded doughnut appearance of the tympanic

    membrane 7 = erythema, bulging, complete effusion and opacification with bulla

    formation

    Friedman et al. Development of a Practical Tool for Assessing the Severity of Acute Otitis Media. Pediatric Infectious Disease Journal. 25(2):101-107, February 2006.

    In the presence of erythema, complete effusion and opacification (grade 5 or above), physicians were more likely to diagnose and treat with antibiotics. Physical examination rather than history has a major influence on AOM management decisions.

  • Otologic System 8 (OS-8) Children aged 6-35 months with parental suspicion of AOM were included.

    A structured questionnaire pertaining the reasons for parental suspicion of

    AOM, symptoms, and score components was filled.

    Laine MK. Symptoms or symptom-based scores cannot predict acute otitis media at otitis-prone age. Pediatrics. 2010 May;125(5):e1154-61.

    AOM cannot be predicted by the occurrence, duration, or severity of

    symptoms at otitis-prone age. Symptom-based scores do not differentiate

    between respiratory tract infections with or without AOM.

    TM examination is crucial in the diagnosis and severity classification of

    AOM in clinical practice and research settings.

  • Tympanic Membrane Bulging

    A bulging TM was highly associated with isolation of bacterial pathogens or bacterial/viral combinations as compared with pure viral or negative cultures (P = 0.01).

    The finding of a bulging ear predicted a bacterial otitis with a positive predictive value of 74% and a negative predictive value of 45%.

    Bulging TMs were also noted somewhat more often in ears infected with S. pneumoniae

    McCormick et al. Otitis media: can clinical findings predict bacterial or viral etiology? Pediatr Infect Dis J. 2000

  • So how can we practically differentiate pneumococcal vs non-pneumococcal AOM?

    Risk factors do not differentiate Parental scoring systems do not differentiate Facial Expressions do not differentiate Symptoms and signs scores do not

    differentiate Otoscopic findings only TM bulging seems to

    somewhat differentiate ??

  • Laboratory Findings

    In children presenting with AOM, the ability to rely on laboratory findings is of interest and can be pragmatic for decision-making purposes, particularly in order to differentiate pneumococcal and non-pneumococcal AOM.

  • Laboratory Findings

    Studies, dating from the pre-pneumococcal conjugate vaccine (PCV) era, foundsignificantly higher WBC counts and neutrophil count in pneumococcal AOM episodes, when compared to Haemophilus influenza positive or in culture-negative AOM episodes

    High CRP levels were more frequently associated with AOM caused by a bacterial origin than viral origin

    Polachek et al. Relationship among peripheral leukocyte counts, etiologic agents and clinical manifestations in acute otitis media. Pediatr. Infect. Dis. J 2004

  • Laboratory Findings Studies from the PCV era found that pneumococcal

    AOM was associated with higher WBCs and CRP levels than non-pneumococcal AOM.

    In pneumococcal AOM, unimmunized children had higher WBC counts when compared with PCV13-immunized children (P = 0.04), but there were noappreciable differences in CRP levels between unimmunised and PCV7/PCV13-immunized children.

    Tamir et al. Severity of pneumococcal versus non-pneumococcal acute otitis media in children. Clin Otolaryngol 2015

  • Conclusions

    No real indicators for AOM severity on real time No reliable parameters predicting severe AOM Non vaccine-type Streptococcus pneumoniae

    strains causing AOM episodes in PCV immunized children yield lower inflammatory responses when compared with unimmunized children.